Further Outpatient Care

Further management of lymphoma patients is outpatient for the most part. The visits are utilized to follow response to treatment and also for psychosocial support to the patient. Follow-up visits are usually arranged every 3-4 months initially, depending on the individual patient, but these may be tailored as the condition mandates. During follow-up visits, it is important to ask patients about unexplained sweating, new lumps, weight loss, and pain. This should be done at every visit, and patients should be educated about reporting any of these symptoms to the physician (see Patient Education).

The physical examination should focus on the presence of enlarged lymph glands and an enlarged liver or spleen. Laboratory workup should be repeated, including the minimum of a CBC count with differential and a comprehensive metabolic panel. Radiologic examination, including chest x-ray, CT scanning of the affected area, and/or PET scanning should be done to follow up the response to therapy.

Some chemotherapy regimens require an inpatient setting, as they are given over several days (eg, up to 96 h in the case of CHOP).

Complications related to chemotherapy that require inpatient management include the following:

Febrile neutropenia

S evere mucositis

B ulky disease with a high chance of developing tumor lysis syndrome

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Inpatient & Outpatient Medications

See the list below:

See the Medical Care and Medication sections for the commonly used agents that are used to treat lymphoma.

Patients are usually given colony-stimulating factors in cases of febrile neutropenia or if the chances of developing neutropenia are high with a certain chemotherapy regimen. Patient are given filgrastim under these circumstances.

Medications aimed at symptomatic relief include antiemetics like prochlorperazine, ondansetron, etc. Steroids and benzodiazepines may be used as adjunctive antiemetic medications.

Adequate analgesia with judicious use of narcotics should be used to control pain when present.

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Transfer

Patients with AIDS-related lymphomas (ARLs) being managed at peripheral healthcare facilities may be transferred to a tertiary care or research institute for access to clinical trials (see Further Reading) and investigational agents.

Patients who are experiencing significant complications from the lymphoma or its therapy should be transferred to a facility that is better equipped to handle such complicated cases.

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Deterrence/Prevention

No preventive measures have been shown to be effective for AIDS-related lymphomas (ARLs); however, the initiation or continuation of HAART has been shown to change the epidemiologic characteristics of ARLs.

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Complications

The complications of AIDS-related lymphomas (ARLs) may be due to the disease itself or may arise as a result of treatment.

Prognosis

A unique characteristic of AIDS-related lymphomas (ARLs) is that HAART can significantly affect the outcomes by reducing viral replication, and their use plays a pivotal role in improving the prognosis. The prognostic index for HIV patients may be adjusted according to age, known as the age-adjusted International Prognostic Index (AAIPI), which has been validated.
[91]

Factors of major prognostic value are as follows:

Age older than 35 years

Stage 3 or 4 disease

CD4 count less than 100 cells/μL

Intravenous drug abuse

When none or one of these factors is present, overall survival is around 46 weeks. When 3 of 4 factors are present, survival is reduced to 18 weeks.
[92]

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Patient Education

Detailed discussions regarding the disease and its management should be done with the patient, with the aim of improved understanding of the disease and compliance.

Patients receiving chemotherapy are at high risk of developing febrile neutropenia and life-threatening infections. They should be instructed to monitor their temperature frequently during treatment and to report fevers immediately, even if they are feeling well.

Patients who are receiving chemotherapy and become neutropenic as a result should avoid eating the following
[56] :

Raw and undercooked eggs

Unpasteurized dairy products

Freshly squeezed unpasteurized fruit and vegetable juices

Fish and seafood

Raw vegetables and raw fruits

Raw, uncooked grain products

Moldy and outdated food products

Patients should be instructed to inform their physicians if they develop chills, diarrhea, sore throat, shortness of breath, cough, or redness and pain at the site of the venous access.

There is a consensus among experts regarding avoiding large crowds, people who have fever, and exposure to animal feces, and regarding maintaining adequate oral and skin hygiene.

Diffuse large B cell lymphoma under high power showing cells that have moderate to abundant cytoplasm, round to irregular nuclear contour, vesicular nuclear chromatin and one to multiple nucleoli. Scattered small mature lymphocytes are seen. Green arrows = atypical lymphocytes; yellow arrows = small lymphocytes.

Gallium scans of a patient diagnosed with small, noncleaved cell lymphoma (SNCCL). These scans show a prominent area of increased uptake in the right cervical region that is suggestive of a gallium-avid tumor.

Sagittal magnetic resonance image (MRI) section of the neck area in a patient diagnosed with small, noncleaved cell lymphoma (SNCCL) (same patient as in Image 5). This image shows a large mass invading the cervical spine with epidural encroachment that also correlates with the site of the tumor in the gallium scan in Image 4. MRI was performed to rule out cord compression.

2-Dimensional (2-D) flow cytometry. These images demonstrate the highlighted cells to be CD5 negative, CD23 negative, as well as lambda negative. The cells are typically CD19+, CD20+, CD22+, and CD10+.

Adnan A Jabbar, MD, PhD Adjunct Clinical Assistant Professor, Department of Medicine, New York College of Osteopathic Medicine of NY Institute of Technology; Fellow, Hematology and Medical Oncology, Emory University

Medscape Reference and the previous authors would like to thank the following physicians for their valuable contributions to this article: Roshan Patel, MD, Department of Pathology, Westchester Medical Center-NYMC and Kyle Bradley, MD, Department of Pathology, Emory University School of Medicine.